The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

New classification for correction of alar retraction using the alar spreader graft

BACKGROUND

Identifying the cause of alar retraction is essential for proper correction of this deformity. In secondary surgery, aimed primarily at cephalic orientation and medialization of the lateral crus, corrections involving spreading and lateralization of the lateral crus can achieve a more horizontal orientation. In their clinic, the authors have practiced the use of an alar spreader graft to support the spread of the lateral crus. For the lateral crus to move freely without any resistance, it is critical to release the nasal hinge and pyriform ligament. A frontal view of the alar notching and the direction of the lateral crus are highly important factors needed to determine the cause of alar retraction. This report describes a new classification system for alar retractions viewed from the front to aid in determining the cause of the retraction and the surgical management.

METHODS

From March 2008 to July 2010, 31 alar retractions were corrected using alar spreader grafts for patients showing clear alar retractions in frontal views.

RESULTS

Satisfactory results without severe complications were obtained in 30 cases, with undercorrection in only 1 case. The alar cartilage was completely released to facilitate lateralization and caudal mobilization. An alar spreader graft then was used to support the lateral crus until a biologic scar cast was formed.

CONCLUSION

The use of alar spreader grafts to correct alar retractions provided consistently good results. The attempt also was made to enhance the treatment strategy based on this classification system derived from frontal views of alar retraction.

LEVEL OF EVIDENCE IV

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Ethnic rhinoplasty

This article examines the surgical techniques of rhinoplasty in relation to aesthetic considerations of various ethnic groups. Rhinoplasty in general is challenging, particularly in the ethnic population. When considering rhinoplasty in ethnic patients one must determine their aesthetic goals, which in many cases might deviate from the so-called norm of the "North European nose." An experienced rhinoplastic surgeon should be able to navigate his or her way through the nuances of the various ethnic subsets. Keeping this in mind and following the established tenets in rhinoplasty, one can expect a pleasing and congruous nose without radically violating ethnicity.

External valve deformity: correction by composite flap elevation and mattress sutures

BACKGROUND

Deformities of the external valve (lateral crus) are an occasional problem following rhinoplasty. One of the most notable problems is when the posterior aspect of the lateral crus curls around into the vestibule. It not only obstructs the airway but can be aesthetically displeasing to the patient. Traditional correction including grafts works can be complicated and often leaves the lateral wall bulky.

METHODS

A U-shaped incision is made around the lateral crus creating a medially based composite flap. This flap contains most of the lateral crus and is delivered into the vestibule for the application of one or more horizontal mattress sutures to the convex surface of the cartilage. These sutures act to straighten out the lateral crus prior to replacing it in its bed.

RESULTS

Seven patients with a deformity of the posterior aspect of the lateral crus received correction by composite flap elevation and mattress suture application. Follow-up ranged from 10 to 33 months. All but one patient had their aesthetic and functional symptoms corrected; this required a symmetry procedure secondary to the loss of alar groove depth.

CONCLUSION

Exposure of the entire lateral curs with the use of a medially based composite flap containing most of the lateral crus is an excellent means to control its shape. Mattress sutures applied to the surface of the cartilage will result in increased stiffness and strength. The net result is a simple correction of what might otherwise be a complicated problem.

Structural grafts and suture techniques in functional and aesthetic rhinoplasty

Rhinoplasty has undergone important changes. With the advent of the open structure approach, requirements for structural grafting and direct manipulation of the cartilaginous skeleton through suture techniques have increased substantially. The present review analyzes the current literature on frequently referenced structural grafts and suture techniques. Individual techniques are described and their utility is discussed in light of available studies and data.

The endonasal lateral crural underlay and sandwich grafts

BACKGROUND

Previously, the problem created by overly convex, wide, and robust lower lateral cartilages (LLC) required an external or endonasal approach with delivery. Although this method has proven invaluable, it may not be indicated in all patients with large tips, specifically those with overly convex LLC or with thin skin and robust LLC.

OBJECTIVE

The authors present the results of their straightforward technique for narrowing the bulbous tip through an endonasal nondelivery approach that reinforces the nasal airway while at the same time preventing alar notching, lateral crus recurvature, and bossa formation.

METHODS

From August 2008 to February 2010, 29 patients underwent endonasal lateral crural underlay and sandwich graft with the authors' technique. All patients had medium to thin skin and prominent, bulbous, symmetric LLC. Three of the patients presented for secondary rhinoplasty. The authors identified no specific contraindications for this procedure. All patients who remained for follow-up were given a questionnaire that analyzed their nasal tip satisfaction on a five-point categorical scale at seven separate points of follow-up.

RESULTS

Among the 27 patients who remained for follow-up, the results were highly satisfactory, mostly satisfactory, or satisfactory in 25 of the 27 cases (as indicated by patient survey). The two remaining patients requested a thinner nasal tip. No significant complications were noted.

CONCLUSIONS

The lateral lower crural underlay sandwich graft is an adjunct to the traditional endonasal approach, further enhancing and expanding the possible outcomes. It appears to equal the predictability and stability identified with traditional tip-narrowing techniques in the external approach but with less operative time, less surgical dissection, and presumably less edema, thereby allowing us to better meet our patients' demands.

External nasal valve collapse repair: the limited alar-facial stab approach

OBJECTIVES

Permanent treatment for external nasal valve collapse (ENCV) is primarily surgical. In some situations, instead of a major operation, the placement of structural alar rim graft may be all that is needed. Alar rim graft placement is usually achieved through a marginal incision as a part of a rhinoplasty. We compared the aesthetic and functional outcomes of a simple technique in which the graft is placed via an external incision in the alar-facial groove with the outcomes of the more commonly used method.

METHODS

All patients who underwent ENCV repair in 2007 and 2008 were reviewed. Fifteen cases in which grafts were placed using the alar-facial stab technique were identified. Twenty cases with marginal incision graft placement in that time period were then randomly selected. All of the patients underwent concurrent additional procedures such as rhinoplasty/septorhinoplasty. The aesthetic and functional assessments of both techniques were explored by means of blinded observers rating the aesthetic outcome and patients rating their functional outcome through the use of questionnaires.

STUDY DESIGN

A retrospective cohort study.

RESULTS

A comparison between the patients' subjective results showed no difference between the outcomes of these two techniques (P > .05). The blinded surgeon evaluators could not differentiate between the different approaches utilized in the vast majority of cases studied.

CONCLUSIONS

The alar-facial stab incision with alar rim grafting for treatment of ENCV is a very simple and effective technique that does not require significant rhinoplasty experience and may be performed in the office under local anesthesia.

Chicken sternal cartilage for simulated septal cartilage graft carving: a rhinoplasty educational model

BACKGROUND

In rhinoplasty, cartilage is often harvested from the nasal septum and meticulously carved into delicate grafts designed to reshape and strengthen the nasal osteocartilaginous framework. Proficiency at this task develops with experience in the clinical setting.

OBJECTIVE

The author offers a simulated educational model designed to provide rhinoplasty surgeons with increased preclinical experience in cartilage graft carving.

METHODS

This model relies on inexpensive, food-grade chickens, which may be purchased at any grocery store. Four whole chickens were dissected to expose and harvest the sternal (breast/keel) cartilage. A technique was developed for preparing the cartilage to approximate the shape and dimensions of human septal cartilage. Measurements were made to demonstrate similarities between the model material and the human septum.

RESULTS

The average weight of the chickens was 4.27 lb. The average cartilage height, length, and thickness were 2.36 cm, 6.13 cm, and 3.4 mm, respectively. This size compared favorably with typical septal harvest pieces, which had both heights and lengths of 2.5 cm and thicknesses of 3.25 mm. The author found that one sternal cartilage piece could be employed to carve two spreader grafts, a columellar strut graft, a tip graft, and two alar rim cartilage grafts. The performance of the avian cartilage was subjectively very similar to that of septal cartilage. Furthermore, two pieces of the sternal cartilage could be glued together and fastened within a model of a human skull to replicate the cartilaginous septum in situ. This construct was employed for demonstrations of actual septal cartilage harvest.

CONCLUSIONS

Carving septal cartilage into grafts is a difficult process. Precision and improved results increase with clinical experience on human patients, but this cadaveric avian (chicken) model provides an opportunity for simulated surgical training on a very similar tissue type at a very low cost. This model has the potential to improve human outcomes by providing increased practice opportunities in a procedure that requires precision and artistry for the formation of reproducible geometric graft shapes.

Preventing alar retraction by preservation of the lateral crus

BACKGROUND

Resecting the cephalic component of the lateral crus in an attempt to reduce tip bulbosity has the potential to aggravate and/or cause alar retraction. It is a more serious problem for those patients who exhibit borderline alar retraction.

METHOD

Fourteen primary rhinoplasty patients with borderline alar/columellar relationships for alar retraction formed the study. They did not warrant frank treatment of alar retraction but did exhibit tip bulbosity. An "island" of cephalic lateral crus was developed by an intercartilaginous incision and another 6 mm cephalic to the caudal border of the lateral crus. One or more mattress sutures were placed in the main body of the lateral crus to stiffen and straighten it. The "island" of cephalic crus was then slipped under the main body of the lateral crus.

RESULTS

At 11 months to 2(1/2) years, 13 of the 14 patients demonstrated no significant change in their preoperative alar/columellar relationships. Bulbosity was corrected in all patients. One patient, however, required a revision using an alar contour rim graft. The mean preoperative alar-nostril axis measurement was 1.48 mm (range, 1.3 to 1.9 mm) in contrast to a mean postoperative measurement of 1.71 mm (range, 1.5 to 2.2 mm). A one-tailed paired t test indicated no statistically significant difference between preoperative and postoperative values.

CONCLUSIONS

The cephalic part of the lateral crus can act as a lateral crural strut to maintain the ala in a more caudal position. The technique is useful for borderline alar retraction and when lengthening the short nose for which there is a need to preserve side wall length.

The hemitransdomal suture for narrowing the nasal tip

The classic transdomal (dome-defining) suture successfully reduces tip width but on occasion also causes a pinched tip (concave alar rim) and an inversion of the lateral crus. We present a modification of that suture technique which only reduces the cephalic end of the dome. By suturing only the posterior (deep) part of the cephalic end of the dome, the lateral crus is everted and a pinched tip is minimized. It is referred to as the hemitransdomal suture because it only reduces the cephalic half of the dome. Twelve cases were studied indicating dramatic correction of dome width without unwanted side effects.

Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery

Congenital anatomic deformities or acquired weakness of the lateral crura of the lower lateral cartilages after rhinoplasty could cause alar rim deformities. As lower lateral cartilages are the structural cornerstone of the ala and tip support, deformities and weakness of the alar cartilages might lead to both functional and esthetic problems. In this article, we are introducing sliding alar cartilage flap as a new technique to reshape and support nasal tip. One hundred sixty consecutive patients between 18 and 55 years of age (mean age: 27.51) were included in the study between January 2007 and May 2008. Of the total number of patients 60 were male and 100 of them were female. None of the patients had rhinoplasty procedure including lower lateral cartilage excision previously. Sliding alar cartilage technique was used in an open rhinoplasty approach to shape the nasal tip in all patients. This technique necessitates about 2 to 3 minutes for suturing and undermining the alar cartilages. The follow-up period was between 4 and 18 months. In no patients any revision related to the sliding alar cartilage technique was required. Revision was applied in 3 patients due to thick nasal tip skin and in one patient due to unpleasant columellar scar. In this article, we are presenting the "sliding alar cartilage flap" as a new technique for creating natural looking nasal tip. This technique shapes and supports nasal tip by spontaneous sliding of the cephalic portion of the lower lateral cartilage beneath the caudal alar cartilage, with minimal manipulation, without any cartilage resection, or cartilage grafting.

Ethnic rhinoplasty

As the United States becomes more racially and ethnically diverse, the number of non-Caucasian patients seeking rhinoplasty is increasing. The non-Caucasian, or ethnic, rhinoplasty patient can be a surgical challenge due to the significant anatomic variability from the standard European nose as well as variability within each ethnicity. Becoming familiar with the common anatomic differences as well as the aesthetic goals in the ethnic rhinoplasty patient will assist the surgeon in attaining consistent, ethnically congruent, and aesthetically pleasing results.

Diagnosis and correction of alar rim deformities in rhinoplasty

Recognition of alar rim deformities is an important component of the preoperative analysis of the nose. Correction of these deformities improves the esthetic balance of the nose and has an added benefit of improving the function of the external nasal valve. Classification systems have been proposed to enable surgeons to more accurately diagnose alar deformities. These classification systems help guide surgeons as to the appropriate surgical procedure to correct a problem. The purpose of this article is to review the proposed classification systems for alar rim deformities and review the specific surgical techniques that have been proposed for each of the deformities.

Middle Eastern rhinoplasty

The ethnic appearance of the Middle Eastern nose is defined by several unique visual features, particularly a high radix, wide overprojecting dorsum, and an amorphous hanging nasal tip. These external characteristics reflect distinct structural properties of the osseo-cartilaginous nasal framework and skin-soft tissue envelope in patients of Middle Eastern extraction. The goal, and the ultimate challenge, of rhinoplasty on Middle Eastern patients is to achieve balanced aesthetic refinement, while avoiding surgical westernization. Detailed understanding of the ethnic visual harmony in a Middle Eastern nose greatly assists in preserving native nasal-facial relationships during rhinoplasty on Middle Eastern patients. Esthetic alteration of a Middle Eastern nose follows a different set of goals and principles compared with rhinoplasties on white or other ethnic patients. This article highlights the inherent nasal features of the Middle Eastern nose and reviews pertinent concepts of rhinoplasty on Middle Eastern patients. Essential considerations in the process spanning the consultation and surgery are reviewed. Reliable operative techniques that achieve a successful aesthetic outcome are discussed in detail.

The importance of maintaining the structural integrity of the lateral crus in tip rhinoplasty

BACKGROUND

A novel technique for maintaining nasal tip support and external nasal valve integrity is proposed. The procedure involves mobilizing the lateral crus to a more cranial position after altering its shape from convexity to a more flat shape.

METHODS

With the described technique, the lower lateral cartilage is dissected free from the skin in a retrograde fashion after an inter cartilaginous incision. The ligament between the lateral crus and the upper lateral cartilage is cut. The vestibular mucosa is not freed. With this maneuver,the lateral crus usually flattens sufficiently. When the convexity flattens, an extra millimeter of cartilage at the cephalic end is gained in the horizontal dimension. When the cut vestibular mucosa is sutured back to its place, the cephalic end of the lateral crus is advanced over the upper lateral cartilage. This technique allows durable support to maintain patency of the nasal valve. No bridges are burned because no cartilage is excised. The surgeon is left with the flexibility to modify the result on the operating table.

RESULTS

The technique was successfully used for 48 consecutive patients over a 3-year period. All the operations were primary rhinoplasties performed using a closed technique. The mean age of the patients was 32 years. For 72% of the patients, septoplasty also was performed. None of these patients had to undergo reoperation.

CONCLUSION

The authors emphasize the importance of the lateral crus in rhinoplasty and demonstrate that good results at the tip of the nose can be accomplished without cephalic trimming, averting related complications in selected cases.

Anchor-shaped nasal framework designed for total nasal reconstruction

BACKGROUND

Nasal frame grafting has been widely used in nasal reconstruction; however, a stable nasal frame with satisfactory functional and aesthetic results is hard to achieve in total nasal reconstruction. In this study, we devised a technique to create an individually designed anchor-shaped nasal frame composed of an L-strut and two C-battens, and applied it in the total nasal reconstruction procedure to achieve satisfactory functional and aesthetic results.

METHOD

In a 9-year period, 17 patients with total nasal defect were treated with autogenous costal grafting utilising forehead flap as the covering. The techniques of the individualised design of the anchor-shaped nasal frame were applied to fit the facial features. All cases were followed for at least 18 months, and outcomes were evaluated separately by the patients and plastic surgeons in terms of aesthetics, stability and function.

RESULTS

Satisfactory results were achieved in most of the cases after the operation. More than 82.4% of the patients in this series were assessed as satisfactory by both groups in the aesthetics survey; more than 76.5% in the stability survey; and more than 64.7% in the function survey. Complications included flap hyperpigmentation (one case), flap-skin paleness (one case), L-strut distortion (three cases) and stuffiness of the nostrils (one case) as well as minor brow elevation of the donor side (five cases).

CONCLUSIONS

The procedure of applying individually designed anchor-shaped nasal frame with forehead flap technique has obvious advantages for restoration of distinct and delicate subunits, stable nasal structure and good nasal function.

Alar batten cartilage graft: treatment of internal and external nasal valve collapse

BACKGROUND

The aim of this study was to describe the efficacy of alar batten graft in correcting internal and external nasal valve collapse (i.n.v. and e.n.v.) and evaluate the functional and aesthetic results.

METHODS

From July 2006 to September 2008, 80 patients (54 females and 26 males) underwent alar batten cartilage grafting. The patients were divided into three groups: (1) 55 patients with iatrogenic nasal valve collapse (80% i.n.v., 20% e.n.v.), (2) 15 patients with posttraumatic nasal valve collapse (45% i.n.v., 55% e.n.v.), and (3) 10 patients with congenital nasal valve collapse (100% e.n.v.). Patients were evaluated at 6, 12, 24, and some at 36 months after surgery. The final follow-up was at least 24 months.

RESULTS

The results of this study revealed a significant increase in the size of the aperture at the internal or external nasal valve after the application of alar batten grafts. All the patients noted improvement in their nasal airway breathing and in their cosmetic appearance. No major complication was observed.

CONCLUSION

The alar batten graft is a simple, versatile technique for long-term reshaping, repositioning, and reconstruction of the nasal valve collapse.

New concepts in nasal tip contouring

The authors introduce the concept of favorable shadowing of the nasal tip surface. Contouring the nasal tip is an advanced concept in rhinoplasty. Several tip altering techniques exist, but proper selection of an appropriate technique or combination of techniques first requires understanding of the impact of manipulating underlying tip structure on nasal surface topography. Frequently, maneuvers that narrow the domes, inappropriately create a pinched or unnatural-appearing nasal tip. Many of these tip-narrowing techniques act to lower the caudal margin of the lateral crura below the cephalic margin and decrease support along the junction between the tip and alar lobule. The nasal tip skin can then collapse on this structure, creating a visible line of demarcation between the tip and alar lobule. Patients will describe their operated nasal tip as having the appearance of a round ball or bulbous tip, even thought their nasal tip may be narrow. This pinched appearance is due to the shadowing that isolates the nasal tip, creating a bulbous or pinched look to the nasal tip. Maneuvers such as dome sutures, lateral crural strut grafts, repositioning of the lateral crura, and alar rim grafts can create a favorable tip structure to support the underlying skin envelope. Using the methods described will enable the surgeon to focus less on narrowing the nasal tip and more on creating favorable shadowing of the nasal tip.

Correction of severe alar retraction with use of a cutaneous alar rotation flap

BACKGROUND

Severe alar retraction is one of the most challenging problems to correct in nasal surgery. Management for severe alar retraction traditionally requires multiple stages and uses several surgical techniques. This article introduces a single-stage technique to correct severe alar retraction deformities using a cutaneous alar rotation flap in conjunction with alar batten grafts.

METHODS

Patients with severely retracted alae underwent ala reconstruction using a cutaneous alar rotation flap and autogenous cartilage batten grafts.

RESULTS

Thirteen patients with severe alar retraction underwent alar reconstruction using cutaneous alar rotation flap and alar batten grafts. The alar retraction was corrected in all cases, achieving improvements functionally and aesthetically. No recurrence of alar retraction was noted. The incision sites for the patients healed with acceptable cosmetic results, with only one patient requiring scar revision.

CONCLUSIONS

The cutaneous alar rotation flap is an effective and reliable surgical option to correct severe alar retraction. Advantages of this technique include a single-stage approach, ease of design, tissue match, and rich blood supply. Scar from the flap design can be kept inconspicuous by precise placement of the incision within the junction of the ala and the nasal dorsum, following principles of the aesthetic nasal subunits.

Rhinoplasty for Middle Eastern noses

BACKGROUND

Rhinoplasty remains one of the most challenging operations, as exemplified in the Middle Eastern patient. The ill-defined, droopy tip, wide and high dorsum, and thick skin envelope mandate meticulous attention to preoperative evaluation and efficacious yet safe surgical maneuvers. The authors provide a systematic approach to evaluation and improvement of surgical outcomes in this patient population.

METHODS

A retrospective, 3-year review identified patients of Middle Eastern heritage who underwent primary rhinoplasty and those who did not but had nasal photographs. Photographs and operative records (when applicable) were reviewed. Specific nasal characteristics, component-directed surgical techniques, and aesthetic outcomes were delineated.

RESULTS

The Middle Eastern nose has a combination of specific nasal traits, with some variability, including thick/sebaceous skin (excess fibrofatty tissue), high/wide dorsum with cartilaginous and bony humps, ill-defined nasal tip, weak/thin lateral crura relative to the skin envelope, nostril-tip imbalance, acute nasolabial and columellar-labial angles, and a droopy/hyperdynamic nasal tip. An aggressive yet nondestructive surgical approach to address the nasal imbalance often requires soft-tissue debulking, significant cartilaginous framework modification (with augmentation/strengthening), tip refinement/rotation/projection, low osteotomies, and depressor septi nasi muscle treatment. The most common postoperative defects were related to soft-tissue scarring, thickened skin envelope, dorsum irregularities, and prolonged edema in the supratip/tip region.

CONCLUSIONS

It is critical to improve the strength of the cartilaginous framework with respect to the thick, noncontractile skin/soft-tissue envelope, particularly when moderate to large dorsal reduction is required. A multitude of surgical maneuvers are often necessary to address all the salient characteristics of the Middle Eastern nose and to produce the desired aesthetic result.

Cartilage Z plasty on lateral crus for treatment of alar cartilage malposition

BACKGROUND

Alar cartilage malposition is an anatomical variation. Axis of the lateral crus lies cephalically and can be parallel to the cephalic septum. The characterised findings of the malposition are broad and bulbous nasal tip, abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities and associated external valvular incompetence. This article presents a new technique for the repositioning of the lateral crus in this article.

METHODS

Open rhinoplasty was conducted. A cartilage Z plasty was performed on the lateral crus of the alar cartilage to treat for malposition. The 14 women and 8 men included in the study had an average age of 27 years (range, 18-46 years). The average follow-up period was 12 months (range, 4-20 months).

RESULTS

Alar cartilage malposition was successfully corrected in patients with aesthetic and functional improvements.

CONCLUSIONS

Cartilage Z plasty can effectively correct alar cartilage malposition. Advantages of this technique can be listed as follows: it does not require extra graft material and protects the lateral crural complex; it does not disrupt movements of the alar muscles and can also serve to adjust projection of the nasal tip.

Tip shaping in primary rhinoplasty: an algorithmic approach

BACKGROUND

Underprojection and lack of tip definition often coexist. Techniques that improve both nasal tip refinement and projection are closely interrelated, and an algorithmic approach can be developed to improve the predictability of the dynamic changes that occur. Use of nondestructive and nonpalpable techniques that enhance nasal tip shape are emphasized.

METHODS

A retrospective review of primary rhinoplasty patients was undertaken to delineate the precise role of preoperative analysis, intraoperative evaluation, and execution of specific surgical techniques in creating nasal tip refinement and projection. Specific case studies are used to demonstrate the efficacy and predictability of these maneuvers.

RESULTS

Successful tip refinement and projection depends on (1) proper preoperative analysis of the deformity; (2) a fundamental understanding of the intricate and dynamic relationships between tip-supporting structures that contribute to nasal tip shape and projection; and (3) execution of the operative plan using controlled, nondestructive, and predictable surgical techniques.

CONCLUSIONS

A simplified algorithmic approach to creating aesthetic nasal tip shape and projection in primary rhinoplasty has been established to aid the rhinoplasty surgeon in reducing the inherent unpredictability of combined techniques and improving long-term aesthetic outcomes.

The intercartilaginous graft for actual and potential alar retraction

BACKGROUND

Alar retraction deformities occasionally require significant soft-tissue release and relatively large cartilage grafts. In addition, correction of the short nose by only lengthening the septum can result in potential postoperative alar retraction. Consequently, both types of cases, true and potential alar retraction (in short noses), would benefit from a technique that lengthens the sidewall of the nose.

METHODS

The intercartilaginous graft technique is a modification of the lateral crural strut graft technique. An intercartilaginous graft is inserted between the upper lateral cartilage and what remains of the lateral crus (lateral crus element). The technique emphasizes maximum soft-tissue release to insert a cartilaginous graft that spans the gap between the upper lateral cartilage and the lateral crus element. The graft is inserted under slight tension to maintain maximum lengthening of the sidewall of the nose.

RESULTS

Thirteen patients had intercartilaginous grafts placed. Seven patients had actual alar retraction and six patients had short noses with potential alar retraction. There was no postoperative alar retraction in 10 patients. Two patients with actual alar retraction were not completely corrected, and one required surgical revision. One patient with a short nose exhibited postoperative alar retraction, but it was not significant enough to warrant reoperation.

CONCLUSIONS

The intercartilaginous graft technique, a modification of the lateral crural strut graft technique, corrects moderate to severe alar retraction and prevents alar retraction after lengthening of very short noses. Its success depends on substantial soft-tissue release and insertion of a maximal sized graft between the upper lateral cartilage and the lateral crus element under slight tension.

[Cartilage grafts in functional and aesthetic rhinoplasty]

Complications after rhinoplasty could often be prevented if less of the support structures of the nose were resected and cartilage transplants were used to give stability. Long-term complications depend heavily on the nasal anatomy, Which is why the surgeon must be able to identify anatomical variants and adapt the surgical technique as necessary. Thus, rhinoplasty techniques have moved away from excisional methods and shifted toward repositioning and restructuring existing tissues. Conservative reduction and preservation of support structures will maximize the aesthetic and functional results. Checking the shape of the tip of the nose is the critical step, and stabilization of the nasal base in particular leads to a good long-term outcome with preservation of the nasal tip projection. The surgeon needs to stabilize the structure of the nose by building up the structure and must also anticipate the effects of scar contracture. This entails structural grafting with autologous cartilage. In this paper, the authors present the grafting techniques most commonly used to sculpt the nasal framework; in primary and secondary rhinoplasty. Tried and tested grafts are presented, with the appropriate nomenclature relating to each and also the anatomical locations of and clinical indications for each.

The anchor graft: a novel technique in rhinoplasty

We review our use of a modified tip graft that we termed the anchor graft for the correction of nasal tip deformities. This modified infratip shield graft was used to improve alar rim positioning, while simultaneously improving tip projection and/or augmenting infratip fullness. Standardized preoperative and postoperative photographs were taken of each patient. Aesthetic appearance was subjectively judged by the physician and a patient survey. Complications were tabulated. Sixteen patients met the requirements for inclusion in our study. Eleven patients received follow-up for more than 1 year. All patients demonstrated good aesthetic improvement, with only minor complications. No extrusion of the graft was noted. All patients reported a natural-appearing and normal-feeling nose after a minimum follow-up of 6 months. Revision surgery was elected in 4 patients, 2 of whom initially presented as revision cases. The anchor graft is a new technique to aid in cosmetic modification of the nasal tip as well as to improve the functional and aesthetic appearance of the nasal ala and external nasal valve.

Definitive repair of the unilateral cleft lip nasal deformity

The majority of patients with a unilateral cleft nasal deformity still benefit from additional nasal surgery in their teenage years, despite having undergone a primary nasal repair. However, the secondary nasal deformity of these patients stands in sharp contrast to those of children who have not benefited from primary repair. The authors' algorithm for the definitive correction of these secondary deformities considers the differences in these two patient groups and defines their indications for rib cartilage grafts and their method of using septal and ear cartilage in the repair. Balancing the muscle forces on the septum and alar cartilage is emphasized in both the primary and secondary repair. Both cartilage malposition and hypoplasia of the lower lateral cartilage complex have been identified as factors contributing to the deformity.

Rhinoplasty

PURPOSE OF REVIEW

Successful rhinoplasty requires a detailed understanding of the nasal structure needed to produce a functional and aesthetically pleasing nose. Recent advances in surgical technique have focused on cartilage repositioning and reshaping, often with the use of cartilage grafting.

RECENT FINDINGS

Newer techniques for strengthening the middle vault, stabilizing the base, and modifying the lateral crura are presented, as well as the M-arch model, a modification of the tripod concept.

SUMMARY

Technical advances in rhinoplasty provide numerous options for reconstruction and reshaping of the nose.

Suture techniques in nasal tip sculpture: current concepts

OBJECTIVES

The three-dimensional anatomy and conspicuous location of the nasal tip makes it one of the most challenging sites of facial plastic surgery. This article reviews literature on nasal tip sculpture using suture techniques, as well as the authors' own experience.

METHODS

A search was conducted using Pubmed, the Google internet search engine and the authors' files, using the keywords 'nasal tip', 'suture', 'rhinoplasty' and 'septorhinoplasty'.

RESULTS

Common nasal tip suture techniques and suture algorithms are presented, along with a summary of the indications and side effects of each technique.

CONCLUSIONS

Predictable long-term results are more likely to occur with minimal local tissue excision. Suture techniques remodel the shape of the nasal tip by altering the configuration of, and the relationship between, the tip cartilages and their supporting structures; they also preserve nasal tip anatomy and limit resection. Intra-operatively, the effects are immediately visible, and can be adjusted or reversed. Tip sutures should therefore be considered instead of tissue excision whenever possible.

New concepts in nasal tip contouring

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.

Management of unilateral cleft lip nose deformity, with retracted ala of the noncleft side

BACKGROUND

Traditionally, the goal of management of unilateral cleft lip-cleft nose deformity has been nasal symmetry, with improved nasolabial and nasofacial relationships and the noncleft side as the reference point. However, symmetry does not always ensure an aesthetically desirable form. The retracted ala is characterized by an alar rim to the long axis of the nostril distance greater than 2 mm on lateral view of the nose. In the management of unilateral cleft lip nose deformity in a patient with a retracted ala of the noncleft side, a simple correction of the deformity symmetric to the noncleft side results in bilateral alar retraction, an aesthetically undesirable result.

METHODS

The authors present eight cases of managing unilateral cleft lip deformities with retracted alae of the noncleft side between January of 2003 and October of 2004.

RESULTS

Correction of alar retraction of the noncleft side with or without the correction of cleft lip nose deformity yielded better aesthetic results that were maintained throughout the follow-up period.

CONCLUSIONS

Aesthetic surgery is the natural evolution of reconstructive surgery; in the reconstruction of selected unilateral deformity, the concept of "as symmetric to the contralateral side as possible" should be changed to the pursuit of an aesthetically pleasing appearance of both sides.

Frequently used grafts in rhinoplasty: nomenclature and analysis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft.

SUMMARY

In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.

The Transvestibular Approach: A New Horizon in Rhinoplasty

The lower lateral cartilage has intricate anatomical elements that define shape, projection, and relations with other nasal tip structures. Good exposure of the lower lateral cartilages is an essential step in rhinoplasty. Conservative surgical techniques are essential to get natural long-term results. Different endonasal techniques have limitations in visualizing the lateral and intermediate crura, predisposing patients to asymmetries in reduction and rearrangement. In this article, a new endonasal rhinoplasty approach is described. Using a marginal incision, the vestibular skin is elevated and the endonasal surface of the lower lateral cartilage is exposed, permitting precise reduction, rearrangement, and placement of interdomal suspension sutures and lateral crural spanning sutures. This article discusses the surgical steps and results of my experience using this approach. This transvestibular approach is a new, dependable, and simple method that should allow rhinoplastic surgeons to perform this operation with predictable results and limited variables.

Components of the short nostril

BACKGROUND

The short nostril, best visualized on the basilar view, is a multifaceted dysmorphology that requires evaluation beyond that of alar/columellar deformities. While the soft triangle is the key component in short nostril disharmony, the alar rim and cartilaginous structures that border the nostrils play a salient role as well.

METHODS

A retrospective review of 200 consecutive rhinoplasties (primary and secondary) examined the specific role of soft triangle excision and other components in the short nostril deformity. Twenty-seven patients underwent soft triangle excision with or without alteration of the other structures influential on nostril length. Of these 27 patients, only three patients required soft triangle excision alone.

RESULTS

The distance from the nostril apex to the caudal border of the alar dome was found to be the crucial element in defining the treatment approach for creating nostril length. When this distance was long, excision of the soft triangle lining and approximation of the alar rim to the lining under the dome elevated the nostril apex and elongated the nostril. When the distance between the nostril apex and overlying dome was ideal or short, soft triangle lining removal was not required, and an optimal nostril length was established by repositioning the other components. Raising the dome using transdomal sutures redirected the wide domal arch vertically, narrowing and lengthening the nostril, provided there was no redundancy in the soft triangle. In a similar fashion, interdomal sutures improved both nostril length and inclination. Placement of a columellar strut also elongated the nostril. An alar rim graft, used primarily to correct alar rim retraction and concavity, also elongated the short nostril.

CONCLUSIONS

The most important factor in analysis and treatment of the short nostril is the extent of the soft triangle tissue present. Soft triangle lining removal is indicated when the distance from the nostril apex to the caudal dome is excessive. This allows the nostril apex to be pulled anteriorly, thus elongating the nostril. The short nostril often coexists with multiple other abnormalities of the nasal base and tip, mandating a comprehensive approach to address all the deformities encountered. Correction of alar retraction also effectively increases nostril length. Further improvement of asymmetric tips and nostrils can be achieved through unilateral soft triangle lining excision with dome equalization through tip suturing and a subdomal graft.

An anatomic study of nasal tip supporting structures

Successful rhinoplasty depends on nasal tip support and its influence on nasal tip projection. It is generally agreed that the components of nasal tip support include the attachment between the upper and lower lateral cartilages, the attachment between the lateral crus of the lower lateral cartilage and the pyriform aperture, the attachment between the paired domes of the lower lateral cartilages, and the medial crural attachment to the caudal septum. However, these structures are still not clearly determined, and there was no anatomic study of nasal tip supporting structures in Asia. The purpose of this study was to determine the nasal tip supporting structures and find out the differences in these structures between white and Asian people. Ten noses of fresh cadavers were investigated. Dissection was performed and the previously mentioned nasal tip supporting structures were observed and excised. Histologic examination was done with hematoxylin and eosin stain and Van Gieson elastin stain. Macroscopic study showed that there were dense fibrous tissue between the upper and lower lateral cartilages, dense fibrous tissue and sesamoid cartilages between the lateral crus and the pyriform aperture, loose connective tissue between the paired domes of lower lateral cartilages, and no identified specific tissue between the medial crus and the caudal septum. Microscopic investigation allowed a more detailed analysis of these structures. Between the upper and lower lateral cartilages, dense collagen fibers were running in one direction and anchoring firmly to each cartilage, which meets the histologic criteria of a ligament. Between the lateral crus and the pyriform aperture, there were intermingled collagen fibers and muscular fibers, which meets the histologic criteria of fibromuscular tissue. Between the paired domes of lower lateral cartilages, there were few fibers with abundant amorphous ground substances, which meets the histologic criteria of loose connective tissue. Based on our results, we recommend that the previously mentioned nasal tip supporting structures should be named intercartilaginous ligament, sesamoid fibromuscular tissue, and interdomal loose connective tissue, respectively. In addition, we consider that the loose connection between the domes of middle crura and the absence of an attachment of the medial crura to the caudal septum can be one of the reasons why the nasal tip of Asian people is broad and unprojected and the base is wide.